The below information is in regards to the base rate codes programs should use when billing Medicaid as well as the rates paid out based on those codes for providing any services covered under New York State Regulation Part 822. General Service Standards for Substance Use Disorder Outpatient Programs.
The downstate peer group includes New York County, Kings County, Queens County, Richmond County, Bronx County, Nassau, Suffolk, Westchester, Rockland, Putnam, Dutchess and Orange counties. The upstate peer group refers to the rest of New York State (ROS).
OASAS developed the APG Medicaid Revenue Calculator to simulate Medicaid revenue projections associated with APG pricing.
Certified outpatient programs may use the tool to continuously monitor and update their projected APG Medicaid revenues. Calculator have the base rates for the respective programs/peer groups; and, the application of the phased payments.
Ambulatory Patient Group (APG) and Federally Qualified Health Center (FQHC) base rates and reimbursement codes for certified outpatient clinics or outpatient rehabilitation programs.
Learn more and find guidance pertaining to outpatient Part 822 services, here.
Opioid Treatment Programs
Ambulatory Patient Group base rates for freestanding OASAS OTPs, hospital-based OTPs, and Article 28 providers.
Effective January 1, 2021, OTP providers billing services for individuals eligible for both Medicare and Medicaid should not bill Medicaid until a claim has been processed by Medicare.
Bundled OTP rates have been calculated consistent with the Medicare bundles and are adjusted for regional factors. Effective August 1, 2021, OTPs may elect to bill either bundled rates or APGs so long as they only bill one methodology for a patient in a given week.
Guidance on billing Sublocade intramuscular injection and oral buprenorphine in ambulatory settings), as well as billing for Vivitrol for outpatient programs.
Please note that changes to Chapters 69 and 71 of the Insurance Laws of 2016 prohibit prior Insurance authorization for medications for treatment of substance use disorder.
Contact Practice Innovation & Care Management Unit
If you have any questions, contact the Division of Practice Innovation and Care Management (PICM).